2024 EMS SILVER APPLICATION

ATTENTION! Onsite Training Activities Postponed At Safety Benefits Inc. the health and safety of our members is always at the forefront. We believe postponing SBI onsite training events at this time is the responsible decision for everyone involved. Please consider taking advantage of the online safety training options available free of charge to SDPAA and SDML-WC Fund members. Call SBI at 605-334-9567 or 888-313-0839 with questions. Thank you! Updates and information on the COVID-19 (Corona Virus) outbreak is available as follows: CDC | SD | South Dakota COVID-19 Information Line 1-800-997-2880

2024 EMS Safety & Loss Control Recognition Awards Application

Service:(Required)

Date:(Required)

Contact Person:(Required)

First Last

Title:(Required)

Address:(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone:(Required)

Email Address:(Required)

Member of (please select one):(Required)

DUE DATE: 01/19/2024

SILVER LEVEL

To achieve a Silver Level award, your service must comply with each of the Bronze Level items and each of the following Silver Level items. Prior levels must be completed as well. Please answer yes or no and attach the appropriate information/documentation as indicated after certain items. To be elligible for Silver Level award in 2024, your service must have had a representative(s) attend the 2023 Annual SD Ambulance Association Conference.

10. Has your service developed a formal Safety Committee and/or appointed a Safety Coordinator? If yes, please provide the information noted below:

* Safety Committee - date formed, number of members, date of last meeting, minutes of meetings for past 12 months * Safety Coordinator - date appointed, duties of Safety Coordinator, etc.

Untitled(Required)

Yes

Attach Documents

Drop files here or

Accepted file types: jpg, pdf, Max. file size: 2 GB.

11. Has your service adopted a formal accident/incident investigation and evaluation program? If yes, please provide the information noted below:

* Attach written policies or an explanation as to how the program works. * If submitted previously, only send a new copy if revised. Note in comments if previously submitted.

Untitled(Required)

Yes

Date Adopted:

Date Revised:

Attach Documents

Drop files here or

Accepted file types: jpg, pdf, Max. file size: 2 GB.

12. Has your service provided back injury prevention/proper lifting training for employees within the past 12 months? If yes, please provide the information noted below:

* Attach a training roster noting the training date(s), trainer, attendees, and the kind of training (safety committee meeting, video, online, in person, etc.).

Untitled(Required)

Yes

Attach Documents

Drop files here or

Accepted file types: jpg, pdf, Max. file size: 2 GB.

13. Has your service provided training on "Preventing Slips, Trips and Falls" within the past 12 months? If yes, please provide the information noted below:

* Attach a training roster noting the training date(s), trainer, attendees, and the kind of training (safety committee meeting, video, online, in person, etc.).

Untitled(Required)

Yes

Attach Documents

Drop files here or

Accepted file types: jpg, pdf, Max. file size: 2 GB.

14. Does your service have a Personal Protective Equipment (PPE) program for employees? If yes, please provide the information noted below:

* Attach written policies or an explanation as to how the program works. *If submitted previously, only send a new copy if revised. Note in comments if previously submitted.

Untitled(Required)

Yes

Date Adopted:

Date Revised:

Attach Documents

Drop files here or

Accepted file types: jpg, pdf, Max. file size: 2 GB.

Safety Benefits Inc.
602 E. State Street
Plankinton SD 57368

605.334.9567
888.313.0839